The biggest mistakes ACL patients make

It’s been almost two years since I had reconstructive ACL surgery. Between personal experience, those I’ve worked with, the emails and comments I’ve received, a few patterns have emerged as to what mistakes I see people making.

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Lack of mental preparation

Far and away the most common thing I get from people, post surgery, is “Oh my god! This is so bad! Is this normal? I’m so miserable. I can’t do anything. The pain is unbearable. I can’t bend my knee, my muscles are disappearing; I’m so depressed.”

I don’t expect everyone to do the amount of research I did for this. I spent over 3 months reading everything I could, talking to people and writing about things. However, if you do even a modicum of research on this topic, you should learn pretty damn quickly it’s normal to:

Not just be down, but to be mind fuckingly depressed after this surgery

Not be able to do anything

Need someone around you for a while after the surgery. I don’t mean a few hours, I mean like a couple weeks.

Be in extraordinary pain

Be on so many drugs you can’t see or think

Be crying

Part of this is definitely the surgeons fault. I don’t know if it’s because the surgeons don’t want people to know how bad things are, or because they become jaded after doing so many surgeries, either way, they do a horrible job preparing people for what this surgery entails. One of the surgeons I saw sent me to his receptionist to schedule surgery without even discussing what the surgery was. I mean nothing was discussed. Not what’s an ACL, why I might need it, the length of rehab, invasiveness of surgery, time off work, NOTHING. Yes, I knew all these things already, but he didn’t know I knew them.

He didn’t even bring up the option of not having surgery. Or the fact I’d be denied health insurance in the future because of having it. If not for the law changes coming in 2014, for the rest of my life I would have severe health insurance issues because of this injury. The insurance companies take this incredibly seriously, so should you.

Part of me gets the lack of understanding; part of me doesn’t comprehend how people don’t understand a power drill will be put through their bones. Look at your leg, imagine a power drill being put through it. Is it really that hard to understand how you’re going to feel after this? “Waa, I can’t bend my leg, waa, this hurts.” No shit, a fucking POWER DRILL was just put through it.

I’m not sure how else to get this across. My only other way is all the people I know who’ve had this done have another big theme to them. Their ACL experience is one of, if not the, worst experience of their lives. Since people love to look to athletes with this stuff, Derek Rose has said his ACL experience is the closest to death he’s ever been, and Wes Welker said he wouldn’t wish his experience even on his worst enemy. Keep in mind these are guys who are, for the most part, ACL success stories! They’re the outliers, and they still had awful times.

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Unrealistic expectations

This goes right with lack of mental preparation. If you even only briefly look around you’ll quickly find how many people are never the same again after this injury. Too many expect to have this surgery and be good as new. The fact of the matter is your leg will never be “normal” again. To reiterate, multiple holes will be drilled through your body, more than likely one of your tendons will be cut apart, it will then be either sewed back together or you’ll hope it grows back, the part of the tendon which was cut off will be screwed into your bones, one or two screws will likely be left in your body, and that tendon will hopefully turn into a ligament with time. Your leg will never feel normal again because it will never be normal again. It has been forever changed.

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That doesn’t mean you’re forever resigned to pain. You can not be in pain but have a leg that just feels weird at times. If you haven’t had surgery, this probably doesn’t resonate. For those who have though, they know exactly what I’m saying. Whether it’s their knee feels weird, it makes odd sounds, the screw moves around, whatever, there is almost always something odd remaining long after the surgery.

“But I’ll be different.”

In Thinking, Fast and Slow, Daniel Kahneman references a time in his younger days when he and some colleagues were writing a textbook. They were projecting how long the book would take and their chances of actually completing it. They pretty much all thought it would be completed, and in about two years.

Kahneman then asks the one colleague who has worked with others who’ve made a textbook, “How many of them actually finished?” The colleague was a bit embarrassed. “Maybe 40%” “And how long did it take those who finished to complete their work?” The colleague was now even more embarrassed. “I’d say the average was about 7 years.”

Kahneman refers to this as the inside and outside view. When you’re on the inside -you’re the person getting the surgery- you think the odds don’t matter for you, or that you’ll beat them. You don’t want to hear that 65% of ACL patients never return to their previous activity level. And even if you do hear it, you’re not listening, or you think you know something they all didn’t. Rather than consider the endless list of NFL players who never made it back after tearing their ACL, you insteadfocus on Adrian Peterson.

It’s not only a physical game; it’s a mental one too. This is what a lot of people miss when trying to come back from this. It’s not just the being able to come back physically, it’s the mental aspect. You very well could get your leg back to its former strength, have no pain, no setbacks, etc. But, you may end up thinking, “I don’t care. I don’t want to go through that again.” Honestly, that’s where I am. I was cleared at 9 months -exactly on time, had no setbacks, went out and played some sports, proved to myself I could do the entire process, then said “I’m done with this shit.” I don’t want to go through all that again. If I (or you) was a million dollar athlete I’m sure my mentality could change, but I’m not. I don’t want to do anything which could increase my chances of going through that whole process again. Physically, I’m able to go back to my previous activity level. Mentally, I’m not.

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Focusing too much on former patient’s experience

Asking those who’ve also had an ACL reconstruction can be productive, but you don’t want to rely on other people’s recounts as you’re only information.

1) Every case is different.

It’s unlikely you’re going to be able to run into someone who is having the exact same surgery as you. Here was my full surgery: Reconstructive ACL surgery with a hamstring autograft, medial meniscal repair, partial lateral menisectomy. Every word of that affects the rehab. Unless you’re talking to a person with the same procedure as you, you’re likely going to have different experiences.

2) Your sample size is too small

ACL surgery isn’t that common. So, you may only have one or two people you know who’ve also had this done. Even if you go online and read 20 different accounts, it’s still a small sample size.

That can greatly skew your perception of what this all entails. Using me as another example: I had basically no pain after my surgery. I have a couple ideas as to why, but regardless, pretty much no pain. This is an aberration. To illustrate how much pain is expected post-op my surgeon prescribed me 80 pills of percocet, all at double dosage (because I’m very tall). He told my dad, “Call me if he needs more.” That’s an insane amount of pills. How many did I take? One, which was the night of the surgery. I only took that because I was afraid a huge flow of pain was about to set in, and I didn’t want to wake up in the middle of the night when it happened.

If you’re someone using me as your reference point for pain after ACL reconstruction, you’re in for a rude awakening when you come out from your anesthesia and realize I was an outlier.

3) You don’t want to put all your faith in people’s memories

Since I brought up Daniel Kahneman, I’ll keep that theme. Kahneman has done some research on our perceptions of how painful an experience was. What’s been found is we remember pain by 1) How intense it was and 2) How it ended. Number 2 is what’s important here.

Tying this to ACL stuff: The worst part of ACL surgery is the beginning. As the process goes on, it normally gets better. You’re more likely to ask fellow ACL patients their experience not right after their surgery, but fairly far out from it. Said another way: You’re more likely to get someone’s recount a year, two, or three years after their surgery, rather than 2 weeks post-op.

Their answer is not only going to reflect things in the early stages, but also how they’ve felt recently. Plus, their recent memories are more available than their older ones. Since people tend to feel better a year, two, or three years after their surgery rather than at two weeks, they tend to mix how they currently feel with how they felt immediately post-up.

Say your friend Jon had ACL surgery. He was a mess immediately post-op, but now at 3 years post op he’s pretty good. He’s not amazing, but he can’t complain too much. You run into Jon, tell him about your current ACL issues, how you’re contemplating surgery, and what’s his advice. How did things go for him? Would he recommend it?

Because Jon feels pretty good now his first response is, “You know, it wasn’t that bad. Not the best time, but I’m pretty good now.” However, if you were next to Jon the day after he woke up and ask him how he was feeling, his response would be, “MAKE IT STOP!”

I have a client Dan who has had upwards of 10 leg surgeries, one of which was an ACL. Dan recently decided to have another leg operation. He came in about a week afterwards. “You know, every time I do this I swear I’m never getting another one. It’s like I forget how bad things are after these things. Then, once I get it done again, it all comes roaring back.”

Me: “It’s like a really bad hangover. You swear you’ll never drink again, but next thing you know it’s Saturday night.”

A much better way of learning what ACL surgery is like is not only to ask former patients, but ask those who were around them right afterwards. If Jon’s dad was his primary caretaker, ask dad what the experience was like. They’ll almost assuredly give you a more accurate description.

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Postponing physical therapy

Many years ago it was common practice after surgery to put the person on bed rest. With leg stuff you’d often be casted up for at least a month and pretty much couldn’t use the leg. Scientifically, those days are gone. We now know this is a terrible way of approaching the post-op period. The longer you don’t use the muscles the quicker and more they atrophy. You increase the person’s risk of blood clots. You also make the physical therapy phase harder as the person is starting from further behind.

Scientifically, those days are gone; realistically, too many still lay around for weeks before doing anything. If there is anything to be learned from athletes in this realm it is that physical therapy after reconstructive ACL surgery does not start a week or two weeks after the surgery, it starts the day of surgery.

There is no reason to wait. You can’t do much right after surgery, but that doesn’t mean you can’t do anything. You can mobilize the patella, wrap the leg, squeeze the quad to make sure it stays awake, as well as work on your range of motion.

Again and again I respond, “Stop worrying about bending your knee, start worrying more about straightening it!”

I think why this happens is after surgery you may lose 10-20 degrees of extension, but 100-120 degrees of flexion. So, to the person, in their mind it’s like, “Holy fuck! I can’t bend my leg at all!” This is normal. The flexion will come with time, and there’s really no need to rush it. In fact, you need to be careful not to push it too much too soon as that can stretch the graft out. Mechanically, especially in the beginning, you will only be able to flex your knee so much anyways, due to the swelling. It’s going to take some time for all the fluid to get out of there.

Extension on the other hand, you need worry about immediately. First, there is no reason to not get all the extension back right away. By this I mean the day of surgery. You don’t have to worry about stretching the graft out with extension. Second, extension is much easier to lose in the long run. Personally, I needed to check my extension multiple times per day. And for about 6 weeks, everyday, I’d gain it back only to lose it again a couple hours later. Third, the longer you go without getting it and keeping it, the more likely you are to never get it back again. All the time I see people with a knee surgery history who years later still can’t fully straighten / hyperextend their knee.

The other thing here is returning to walking. It’s ok if you can’t bend your knee to 120 degrees, or hell even 90 degrees, that’s not going to affect walking. However, if you can’t fully straighten your knee, that’s a really bad knee to be walking on. You end up walking on a bent knee all the time, which beats the hell out of your joint. So, working on full extension helps get you back to healthier walking while obsessing over bending your knee does not. There is a progression here, and the ability to walk again is very high on the hierarchy. Certainly much higher than bending your leg.

Full, complete flexion will take months and months, and that’s ok. Stop worrying so much about it.

Which brings us full circle: If you only do even a bit of preparation, you should know not to bend your leg too soon, that you won’t be able to bend your leg, that you should be extending it, that you’re going to have a lot of pain and discomfort, etc. Just a couple questions to the surgeon will let you know this.

This often ends up being a $50,000 surgery, with power drills, screws, knives, hours of anesthesia, high level pain killers, a significant degree of short term disability, minimum 6-9 months of physical therapy, you get the idea.

For Christ’s sake do your homework.

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For more information on what to do coming out of ACL surgery, or if you’re someone who needs to take a step back and reboot the process, check out my manual The most important phase of ACL rehab. Click link for more info, or click below to purchase

I cover extension ROM fairly thoroughly in the ACL manual, but this is more extensive than before. Also, some have asked me, “I’m more than a month out, will your ACL manual still apply?” While the answer to that is usually yes, now I have the extension manual for those are only specifically looking at that.

Post-script (Update 7/1/15)

Understand this coming from a place of wanting to see people do this process better. It is not meant to be judgment, or beratement.

I’m not sure what’s going on the last week or two, but some themes that keep coming up:

1) There seems to be an overall lack of acknowledgment about how long a process this is. Many of you have probably heard “6-9 months,” which is one reason I didn’t hit on this in the article. I assumed it’d be rare to to complain about progress at 2-3 months, as it ignores the fact you have, at least, *double* that amount of time to go. But I’m seeing this more than I thought.

Plus, in reality, this is an 18-24 month process. The 6-9 month mark is more, “Yeah, I’m running again, have full ROM, no issues with walking…but it’s not like I’m playing sports without worrying about it.” FULL recovery is upwards of two years, *IF EVER.*

2) There is either a lack of reading before commenting, or a degree of denial. Because either people aren’t reading the section on “Obsessing over flexion over extension,” or they want to ignore it. So many comments here are about lack of ability to bend the knee. At 2-3 months of all things!

Part of me thinks I need to write a sequel to this post. The other part of me thinks people need to read the following paragraph from the post until it really sinks in:

“Full, complete flexion will take months and months, and that’s ok. Stop worrying so much about it.”

I made two sentences its own paragraph specifically so it would stand out. “Months and months” is not one, two, or three months. It’s MONTH*S* and MONTH*S*.

I understand this is a traumatic time for many who come across this article. But I, nor anyone, can propel your physiology into a different state. It sucks an injury from perhaps out of nowhere, can fuck your mind and life up so much, but it is reality.

And if you’ve chosen the path of surgery, you’ve chosen a very, very brutal, long, tedious, depressing, handicapped, lonely, path. One in which there are no guarantees you come out better for having it. You very well could come out worse.

Much like we all degenerate with age, and need to accept it at some point or live in delusion, there are realities to tearing your ACL we all need to accept. The first step to getting over any problem is full acknowledgment of the reality of the problem. I promise many of you, if you get to this point sooner, a sense of relief will come over you.

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Thanks for your post. I’m in desperate need of surgery and your post has confirmed it is my last resort. PT hasn’t helped and my mobility has declined in the last 6 weeks to the point I’v not been out the house in 2 weeks and looking at buying a mobilty scooter. I already can’t bend or straighten the knee & my other leg & hips are causing great pain. I simply can’t walk at all now.

I had brain surgery 9yrs ago so I’m hoping that experience will set me up mentally at least to cope with my ACL repair.

Hi Brian, thanks for your post! You hit so many points of reality here. It’s almost as I am reliving my nightmare AGAIN! I have had ACL reconstructive surgery, the same as yours except both of my meniscus needed to be repaired and shaved down, my ACL was replaced with one of my hamstrings and I did have the bloody power drill through my knee…I’m cringing at the memories. And YES, STRAIGHTENING YOUR KNEE IS SOOOOO IMPORTANT, I didn’t get this at first but yes yes yes…focus on straightening the knee, it will bend eventually as Brian has stated. If you don’t do this then your knee will heal with a slight bend and scar tissue will form and you will basically have a minor limp and your body weight will be distributed unevenly and cause stress and complications with your ENTIRE BODY…especially your back. Just do it, you’ll be thankful you did. It’s been 4 years since my surgery and I AM STILL NOT back to where I was pre-op, I most likely never will…yes people listen up, it is NOT a miracle surgery, everyone is different so be prepared for that and you may never be the same again. I recently had to visit another surgeon and guess what???…I was told I need another surgery to correct the first surgery…what.the.****. Needless to say I heard that and burst in to tears…I remember my experience and I never ever wanted to go through that again. So now I’m stuck…DO I? DON’T I?… Apparently the first surgery worked but the ligament healed too straight and didn’t heal at an angle so my knee slips out from time to time, hence the new cartlidge tear I have. Once healed the ACL/MCL should be more of a “X” shape over/behind the knee so the knee pivots and moves side to side as it is suppose to and not slide off, like mine is vulnerable to. My ACL has healed more straight up and down because of placement of the screw that guides the ACL over my kneecap. Going back to the suggestion of surgery from a NEW surgeon, of course there’s a new and better and less invasive way of doing the surgery…OF FREAKIN COURSE. SMH. (Do the research people… pre-carving.) I agree with your statement in the post about how the doctors don’t even explain any of the surgery to you or even the specifics of what happened to your knee and why this needs to happen or alternate options…THIS.IS.SO.SCARY. The only reason I asked so many questions this time around was 1) I had the surgery already, so I was more aware and traumatized. 2) I had read up on more research. 3) This time around I had a slew of questions for the MD to answer, and I didn’t let him leave until they were answered…none of this 5 minutes in the room with me mess. I was generally better prepared, which people I implore you to do the research, don’t just go with whatever the doctor says is best. DO THE RESEARCH. ASK QUESTIONS. I don’t care how uncomfortable or how imposing you think you are being…ASK ASK ASK your doctor questions! This is your knee, you know one of the two things that hold you up and allow you to walk, very important appendages take care of them. This kind of injury and surgery CAN/DOES INDEED CHANGE YOUR LIFE FOREVER. I don’t want to scare anyone off, if you need it you need it and there’s not much room around it…which was my case…but if I had done better research and asked more questions I would’ve opted for a different surgery or a second opinion…I was ignorant to it. I just went with what was suggested. NEVER AGAIN, lesson learned…the hard way. My knee will never be the same and I am so young…too young, and I will forever be effected by this. I never appreciated my knees as I do now…it has definitely put many things into perspective. Back to the current situation…I’m having a difficult time considering the second surgery which will correct the issue from the first surgery but if I don’t have it I will continue to have issues and never get full range of mobility back…it was such a horrible experience the first time around. Pre-injury/surgery I was an extremely active and reasonably fit individual…since surgery that has definitely taken a back seat, I can’t move the way I used to, it has gotten better, but I think a big part is MENTALLY…I’m so aware of how I step, to pay attention to curbs, to watch for rocks and how I step…IT.IS.INSANE how much I am paranoid and watchful of how I step. I am desperate to get close enough to a level of activity I was before but I am terribly afraid to re-injure my knee again but at the same time also terrified to go through surgery again…

Hi Natacha,
Sorry to hear about the complications. My husband is having this surgery tomorrow and I was wondering what you mean by the knee healing too straight? We are considering getting a knee lock brace for him to sleep but should he not have his knee completely straight?